Introduction: Early identification of patients at risk for severe multisystem inflammatory syndrome in children (MIS-C) is essential for favourable clinical outcomes. This study aims to identify the clinical characteristics, factors and outcomes associated with severe MIS-C. Materials and methods: In this retrospective cohort study involving 14 major hospitals in Malaysia, children <15 years who met the United States Centres for Disease Control and Prevention case definition for MIS-C were included. Severe MIS-C was defined as children who required inotropic support, ventilatory support (invasive or non-invasive ventilation), or left ventricular ejection fraction of <55%. The factors investigated for severe MIS-C were demographic characteristics, the presence of comorbidities, clinical characteristics, and laboratory measures. Multivariable logistic regression was used to compute the adjusted odds ratio (aORs) of factors associated with severe MIS-C. Results: Among the 155 patients, 91 (58.7%) presented with severe MIS-C. Severe MIS-C was more likely in patients aged ≥5 years old (aOR 2.13, 95% confidence interval [CI] 1.08-4.21), with dehydration (aOR 3.80, 95% CI 1.53-9.45), lethargy (aOR 2.02, 95% CI 0.97-4.18), tachycardia (aOR 8.33, 95% CI 3.27-21.22), albumin <30g/L (aOR 3.36, 95% CI 1.58-7.13), creatine kinase >200U/L (aOR 3.68, 95% CI 1.57-8.64), D-dimer >3.0µg/mL (aOR 2.11, 95% CI 1.08-4.13), ferritin >500ng/mL (aOR 3.77, 95% CI 1.88-7.55), prothrombin time >12.7 seconds (aOR 3.22, 95% CI 1.61-6.43), and urea >6mmol/L (aOR 5.09, 95% CI 2.04-12.71). Conclusion: Identification of these associated factors of severity in MIS-C could aid in early recognition and prompt escalation of care, leading to better outcomes.

The present study aimed at exploring whether sunlight exposure might account for the relative difference in COVID-19-related morbidity and mortality between tropical and non-tropical countries. A retrospective observational study was designed and data from the World Health Organization weekly COVID-19 epidemiological update was compiled. We examined the total number of confirmed COVID-19 cases per 100 000 population, as well as the total number of COVID-19-related mortalities per 100 000 population. Solar variables data were obtained from the Global Solar Atlas website (https://globalsolaratlas.info/). These data were analyzed to determine the association of sunlight exposure to COVID-19-related morbidity and mortality in tropical and non-tropical countries. Results revealed a statistically significant decrease in the number of confirmed COVID-19 cases per 100 000 population (P<0.001), as well as the number of COVID-19-related mortalities per 100 000 population (P<0.001) between tropical and non-tropical countries. Analyses of sunlight exposure data found that specific photovoltaic power output, global horizontal irradiation, diffuse horizontal irradiation and global tilted irradiation at optimum angle were significantly inversely correlated to COVID-19-related morbidity and mortality. This suggests that stronger sunlight exposure potentially leads to lower COVID-19-related morbidity and mortality. Findings from this study suggest that the relatively low COVID-19-related morbidity and mortality in tropical countries were possibly due to better sunlight exposure that translates into adequate vitamin D status.

Methods: In total, 185 lesions were identified on bone and SPECT-CT scans from 32 patients. Lesions were classified as metastatic (109 sclerotic lesions) and benign (76 lesions) morphologically on low-dose CT. Semiquantitative analysis using SUVmax and mean HU was performed on the lesions and compared. To discriminate benign and metastatic lesions, the correlation between SUVmax and mean HU was determined using the intraclass correlation coefficients. Results: The SUVmax was higher in metastatic lesions (20.66±14.36) but lower in benign lesions (10.18±12.79) (p<0.001). The mean HU was lower in metastatic lesions (166.62±202.02) but higher in benign lesions (517.65±192.8) (p<0.001). A weak negative correlation was found between the SUVmax and the mean HU for benign lesions, and a weak positive correlation was noted between the SUVmax and the mean HU on malignant lesions with no statistical significance (p=0.394 and 0.312, respectively). The cutoff values obtained were 10.8 for SUVmax (82.6% sensitivity and 84.2% specificity) and 240.86 for the mean HU (98.7% sensitivity and 88.1% specificity) in differentiating benign from malignant bone lesions. Conclusions Semiquantitative assessment using SUVmax and HU can complement qualitative analysis. Metastatic lesions had higher SUVmax but lower mean HU than benign lesions, whereas benign lesions demonstrated higher mean HU but lower SUVmax. A weak correlation was found between the SUVmax and the mean HU on malignant and benign lesions. Cutoff values of 10.8 for the SUVmax and 240.86 for the mean HU may differentiate bone metastases from benign lesions.

Purpura fulminans (PF) is a severe clinical manifestation of Neisseria meningitides infection that is associated with high mortality rates in children. Survivors are frequently left with debilitating musculoskeletal sequelae. There is a paucity of reports on the musculoskeletal pathology of purpura fulminans. We report on a 2-year-old boy with purpura fulminans due to meningococcemia. The child developed distal gangrene in both the upper and lower limbs. Amputations were done for both lower limbs. Histological examination of the amputated specimens showed an inflammatory process and features of osteonecrosis. The latest follow-up at the age of 6 years showed a right knee valgus due to asymmetrical growth arrest of the proximal tibia. PF and its complications are challenging to treat and may require a multidisciplinary approach to improve patient’s functional ability.

Introduction: To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods: Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results: All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions: A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.

Introduction: Open tendoachilles injuries are rare and associated with significant soft tissues complications. The objective of the present study was to assess the clinical outcome and safety of a simple and minimally invasive technique, with a goal to assess if it may help minimise flap and wound related complications in open tendoachilles injuries. Materials and methods: This prospective study of four years duration included 20 patients with open tendoachilles injuries managed with a simple minimally invasive tunnel technique. The primary outcome variable was occurrence of a major soft tissue complication. The secondary outcome variables included functional outcome measured using AOFAS Ankle hind foot score, re-rupture of tendoachilles and need for revision surgery. Results: None of the patients in the present series developed a serious soft tissue complication. Based upon the AOFAS hind foot scoring system, good to excellent outcome was achieved in 19 (95%) patients. All the patients were able to perform tip toe walking at six months post-surgery. None of the patients had a re-rupture of the tendoachilles and no patient needed a revision surgery. The complications encountered include thickening of the tendon at the repair site (15%), superficial wound infection (5%), stitch granuloma (5%) and hypertrophic scar (5%). Conclusion: This technique seems to be promising in reducing the soft tissue complications associated with the surgical management of open tendoachilles injuries. Most patients had a good final clinical outcome. The technique is safe, simple and reproducible. However, further randomised control studies with a larger sample size assessing the technique are recommended.

Introduction: In Malaysia, the adolescent health studies conducted in 2012 and 2017 revealed an increasing trend of adolescent health risk behaviours and protective factors. This current study aims to determine health risk behaviours and protective factors among adolescents in the country. Methods: The current nationwide cross-sectional study of Malaysian secondary school students used multistage stratified sampling to select 240 nationally representative schools. This study was conducted from June to July 2022 among the students in forms 1, 2, 3, 4, and 5 in all Malaysian states by 34 data collection teams. A validated self-administered questionnaire was used, similar to those used in the NHMS 2012 and NHMS 2017. The quality control was done twice, once at the field level and once at the central level. Sample weighting and analysis were conducted using SPSS statistical software version 28.0. Results: A total of 239 schools out of 240 schools took part in the study (response rate, 99.6%) and total of 33,523 students were involved in this study (response rate, 89.4%). In terms of ethnicity, the highest number of students who participated in the study were Malay (63.0%), followed by Chinese (18.1%) and Indian (6.0 %). While the distribution of sex and form among the students were almost the same. Conclusion To obtain an accurate representation of the nation's adolescent population for this study, samples from public and private schools that are governed by the Ministries of Education and Rural and Regional Development were deemed to be the most reliable.

“Fake braces” is a term used to describe fixed orthodontic appliances that are fitted by unlicensed providers. This trend has raised public health concerns in certain countries with marketing typically undertaken on social media. We aimed to investigate the frequency and nature of Instagram posts by fake braces providers in Malaysia. Initial screening of Instagram accounts was performed using relevant hashtags (#fakebraces, #cheapbraces). Public Instagram accounts that fulfilled the inclusion criteria were assigned a code with posts evaluated over a one-month period. Data were coded and analysed using thematic analysis. Frequency distribution was calculated using Microsoft Excel. Thirty-eight Instagram accounts were analysed. 2831 images/videos were posted, receiving 7165 likes with videos being viewed 21, 918 times. The majority of posts were related to fake braces services (36.7%), followed by non-relevant posts (29.4%) and other services (14.5%). Services were provided mainly at home (44.7%) or offered both home and door-to-door services (23.7%). Although the posts on promotions were less frequent (5.4%), the displayed prices were low (RM150 to RM500), offering additional packages and discounts. Unlicensed providers have a variety of content to engage with social media audiences. Efforts should be made to increase public awareness, directing them towards reliable information about orthodontic services.
Orthodontics

Background: Most undergraduate dental students were concerned regarding the transmission of the COVID-19 virus through their profession. This dread and anxiety may be attributable to a lack of comprehension regarding the necessary precautions and protocols to implement to ensure safety and limit potential infection threat. This study aims to assess COVID-19-related knowledge, attitudes, and practices (KAP) among undergraduate dental students at the Faculty of Dentistry, Universiti Malaya. Methods: A cross-sectional study design was used, involving 166 respondents who were undergraduate dental students from years II to IV. Data collection was achieved using a pre-tested web-based questionnaire. Descriptive and inferential analyses, including independent t-tests and one-way analysis of variance (ANOVA) tests, evaluated the KAP differences related to demographic factors. Results: There were no statistically significant differences in mean KAP associated with demographic factors such as gender, place of residence, and year of study (p > 0.05). Conclusions Dental students at the Faculty of Dentistry, Universiti Malaya, Malaysia, had adequate knowledge of COVID-19 in light of the country’s quarantine status and pandemic context.
COVID-19

Coccidiosis is a major recurring problem in the poultry industry and is caused by infection of one or more of the seven Eimeria species known to infect chickens, with Eimeria tenella among the best studied and economically important. Studies on the genetic diversity of E. tenella strains is essential for the development of universally acceptable diagnostic markers and vaccines against the disease. Eimeria tenella internal transcribed spacer-1 (ITS-1) and apical membrane antigen-1 (AMA-1) sequences from different parts of the world are available in the public domain and therefore provide suitable comparative markers for genetic diversity study. In this study, the ITS-1 and AMA-1 sequence diversity of two local E. tenella strains, namely EtNSN6 and EtSGR6 were characterized. Both ITS-1 and AMA-1 sequences for EtNSN6 and EtSGR6 were retrieved by mapping to their respective genome sequences generated using next generation sequencing. Multiple sequence alignment of the ITS-1 and AMA-1 sequences with selected homologous sequences revealed the presence of a total of five and 13 single nucleotide polymorphisms (SNPs) respectively. All SNPs appeared to occur at random and did not show any unique pattern based on geographical regions while no insertions and deletions (indels) was found to occur in the aligned sequences. However, unique bases that defined certain strains were detected. Phylogenetics analyses performed with Maximum Parsimony (MP) and Maximum Likelihood (ML) methods revealed similar topology for the internal groups with all the E. tenella ITS-1 and AMA-1 sequences grouped in the same clade supported by high bootstrap confidence. This confirmed that both EtNSN6 and EtSGR6 samples are E. tenella strains. Sequence comparison and phylogenetics analyses further suggest the possibility of low genetic diversity among E. tenella strains.